casestudy2 xACIdischargeplanaseessment21 x
Neurological Case Study
Case Study
Mr Sam Kwon is a 74-year-old man (Medical Record Number (MRN) 684421). He was brought in by paramedics with right-sided hemi-paralysis, aphasia and facial drooping. He has a history of hypertension, congestive cardiac failure, and type 2 diabetes mellitus.
He takes oral hypoglycaemic agents. He has also smoked a pack of cigarettes a day for approximately 40 years. His observations were as follows:
|
Temperature |
Heart rate |
Respiration rate |
Blood pressure |
SpO2 |
|
36.8°C |
98bpm |
24/per minute |
140/105mmHg |
96% (room air) |
A CT scan without contrast suggested a probable left cerebrovascular accident, with increased density in the left middle and cerebral artery and possible early signs of oedema.
From these results, it is expected that Mr Kwon may also be experiencing homonymous hemianopia, but communication is difficult at this stage.
As he is aphasic he requires a communication board, however, he can answer with a head nod to closed questions.
Mr Kwon’s BGL is 9.4mmol/L. He has basal crackles and has been placed on oxygen at 2L/min via nasal prongs. A swallow review has been booked for today; meanwhile he remains nil by mouth.
The time of the incident is currently unknown as his family have been out since early morning and did not find him until late last night.
The team were unable to dissolve the clot. Mr Kwon requires q2h turns, he has an IV catheter in situ and is receiving crystalloid fluids. He also requires q2h BGL tests at this stage he is for review later today.
Task Details
1.
Analyse and interpret the assessment findings for Mr Kwon.
2. Based on your analysis and interpretation, develop an interprofessional care and management plan for Mr Kwan. In your plan, address:
1.
· Ethical and legal implications
· Person-centred care
· Health promotion strategies.
Support your plan with current evidence-based literature.
3. Over the next 14 days, Mr Kwon’s condition improves to a point where the doctor is happy to discharge him home. His gait is steady and unaided, his speech has improved but still slurred. He has recovered some movement on his right side and it is likely a deficit will remain. With this new information and your initial notes about his lifestyle/history, develop a discharge plan. Complete the attached discharge plan form.
Justify your discharge plan decisions with reference to the literature.
Assessment Criteria
You will be assessed on your ability to:
1. Identify and analyse key case findings and draw logical conclusions. (30)
2. Develop and prioritise care strategies that flow from your analysis. (30)
3. Explain your decisions in a clear and logical way. (20)
4. Incorporate relevant ideas from the literature in your writing that support your argument. (10)
5. Use academic English, grammatically correct sentences and APA style for references. (10)
Criteria Led Discharge (CLD)
Planning for discharge on admission
A RESOURCE DEVELOPED BY THE ACI ACUTE CARE TASKFORCE TO SUPPORT IMPLEMENTING CRITERIA LED DISCHARGE
AGENCY FOR CLINICAL INNOVATION
Level 4, Sage Building 67 Albert Avenue
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PO Box 699
Chatswood NSW 2057
T +61 2 9464 4666 | F +61 2 9464 4728
E
info@aci.health.nsw.gov.au
|
www.aci.health.nsw.gov.au
Produced by: ACI Acute Care Taskforce Ph. +61 2 9464 4623
kate.lloyd@aci.health.nsw.gov.au
SHPN (ACI)140244
ISBN 978-1-74187-050-3
Further copies of this publication can be obtained from the
Agency for Clinical Innovation website at: www.aci.health.nsw.gov.au
Disclaimer: Content within this publication was accurate at the time of publication.
This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation.
© Agency for Clinical Innovation 2014
iv Criteria Led Discharge (CLD) : Planning for discharge on admission
Criteria Led Discharge (CLD) : Planning for discharge on admission
iii
ACKNOWLEDGEMENTS
The Agency for Clinical Innovation (ACI) is the lead agency in NSW for promoting innovation, engaging clinicians and designing and implementing new models of care. All ACI models of care are built on the needs of patients, and are underpinned by extensive research conducted in collaboration with leading researchers, universities and research institutions.
The ACI acknowledges that we operate and function on the lands of the Cammeraigal people of the Eora Nation. We acknowledge and pay respect to the ancestors that walked and managed these lands for many generations. We pay respect to Elders past and present and extend that respect to other Aboriginal peoples present here today. We acknowledge elders who are the knowledge holders, teachers and pioneers. We acknowledge the youth who are the hope for a brighter future and who will be the future leaders.
For further details on the ACI, visit: www.aci.health.nsw.gov.au
The ACI acknowledges the large number of people involved in the development of this resource for CLD, in particular:
· ACI Acute Care Taskforce
· ACI Criteria Led Discharge Working Group
· Auckland District Health Board
· Bega Hospital (Surgical Ward)
· Calvary Mater Hospital (Haematology Unit)
· Children’s Hospital Westmead, NSW
· Clinical Excellence Commission – initial draft of this document
· Department of Health / National Health Service, UK
· Queensland Health
· Royal Children’s Hospital Melbourne, Victoria
· The Nursing and Midwifery Office at the NSW Ministry of Health
· Wollongong Hospital (Cardiology Step Down Unit, Neurology Ward)
CONTENTS
GLOSSARY 1
ACRONYMS 1
Background 2
Increasing demand on our health facilities 3
Patient transfers of care 3
A Solution – Criteria Led Discharge 5
An Enabler: A Patient Flow Systems Approach 9
The Criteria Led Discharge Framework 6
Implementing Criteria Led Discharge 7
Supporting Documentation 9
References 10
APPENDIX A: FREQUENTLY ASKED QUESTIONS FOR IMPLEMENTING CLD 11
APPENDIX B: PATIENT INFORMATION SHEET FOR CLD 12
APPENDIX C: CRITERIA LED DISCHARGE TEMPLATE 13
APPENDIX D: GUIDANCE ON CRITERIA LED DISCHARGE FORM 14
APPENDIX E: TRANSFER OF CARE CHECKLIST 15
APPENDIX F: PATIENT AND STAFF EXPERIENCE – PATIENT EXPERIENCE TRACKERS (PETS) 16
APPENDIX G: DRAFT PROTOCOL/POLICY FOR LOCAL ADAPTATION 17
APPENDIX H: A Competency Statement for Criteria Led Discharge 18
APPENDIX I: A Checklist for Implementing Criteria Led Discharge 19
APPENDIX J: A set of education/orientation slides for CLD 20
GLOSSARY
MEANS
Admission1
Admission to hospital is a formal process, and follows a decision made by a medical officer that a patient needs to be admitted for appropriate management or treatment of their condition, or for appropriate care or assessment of needs. Separation is the term used to refer to the episode of admitted patient care.
Bed block
A situation in which a patient stays in hospital because there is no other suitable place to which they can be transferred. This also means that other patients cannot enter the hospital when they need to, because there are no beds available for them.
Discharge
See transfer of care.
Interdisciplinary2
This document uses the terms interdisciplinary and multidisciplinary to mean the same thing. Although this resource recognises that a multidisciplinary team utilises the skills and experience of individual team members from different disciplines, with each
discipline approaching the patient from their own perspective. An interdisciplinary team
approach attempts to integrate separate discipline approaches into a single method.
Multidisciplinary
See interdisciplinary.
Separation1
Separation is the term used to refer to the episode of admitted patient care. A separation, which can be a total hospital stay (from admission to discharge, transfer or death) or a portion of a hospital stay beginning or ending in a change of type of care (for example, from acute care to rehabilitation).
Transfer of Care
This term is used interchangeably with discharge. It involves the transfer of professional responsibility and accountability for some or all aspects of care for a patient to another person or professional group on a temporary or permanent basis.
ACRONYMS
MEANS
ACI
NSW Agency for Clinical Innovation
CEC
Clinical Excellence Commission
CLD
Criteria Led Discharge
CMP
Clinical Management Plan
EDD
Estimated date of discharge
HETI
Health Education & Training Institute
LHD
Local Health District
LOS
Length of stay
MOH
Ministry of Health
PET
Patient Experience Tracker
PFP
Patient Flow Portal
SHN
Speciality Health Network
20 Criteria Led Discharge (CLD) : Planning for discharge on admission
Criteria Led Discharge (CLD) : Planning for discharge on admission
23
Background
The Acute Care Taskforce (ACT) has been involved in developing solutions for improving the medical
patient journey since 2005. This includes work around safe clinical handover, avoidable admissions and the establishment of medical assessment units.
In 201 the NSW Ministry of Health published a policy directive titled Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals. Acknowledging that patient involvement contributes to positive health outcomes, the policy mandated that hospital teams involve patients/carers in care planning. It highlights five important stages to a coordinated inpatient experience:
1. Pre Admission/Admission
2. Multidisciplinary team review
3. Estimated date of discharge (EDD)
4. Referrals and liaison for patient transfer of care
5. Transfer of care (discharge) out of the hospital
In 2012 the ACT transitioned to the NSW Agency for Clinical Innovation (ACI) and in order to build upon this important work the ACI brought together a group of clinicians, consumers and managers. Under the
guidance of this group the ACT decided it would focus on improving the medical inpatient journey in 2013.
Five important elements to improving the inpatient journey were identified with the system lead noted in brackets ():
1. A patient flow systems approach to improving the inpatient experience focused on the estimated date of discharge (EDD) and Waiting for What? functions (NSW Ministry of Health – MOH and Health & Education Training Institute – HETI)
2. Inpatient clinical management plans (ACI)
3. Ward rounds (Clinical Excellence Commission – CEC)
4. Criteria led discharge (ACI)
5. Transfer of care / discharge (CEC)
Under the guidance of the ACT Executive, two working groups were established: one for clinical management plans (CMP) and another concentrating on criteria led discharge (CLD). Following a comprehensive literature review and in consultation with the statewide ACT the clinician led working groups developed a set of tools to assist staff from Local Health Districts and Specialty Health Networks (LHD/SHNs) to:
· Improve documentation of the CMP in their wards and facilities, and/or
· Assess the requirements for implementing CLD. This resource is focused on CLD.
Figure 1 Acute Care Taskforce 2013: a collaborative approach to improving the medical inpatient journey
WHOLE OF HOSPITAL ACCESS TO CARE
in the
co ity
Patient
mmun
Patient enters the service
ED to Inpatient
Inpatient to Inpatient
Patient
exits
s
ervice
Patient in the community
Medical Assessment Unit
Hospital in the Home
PATIENT FLOW
Estimated Date of
Discharge
Wa hat
iting for W
Interdisciplinary Ward Round
Clinical Management Plan
Criteria Led Discharge
Transfer of Care
Bed Management
Leads
MOH
ACI
Educational materials on ‘smooth patient flow’ across the patient journey:
CEC
LHD/ SHNs
HETI
LHD/SHNs = NSW Local Health Districts and Specialty Networks
MAU = Medical Assessment Unit HITH = Hospital in the Home
HETI = NSW Health Education and Training Institute MOH = NSW Ministry of Health
Key
ACI = NSW Agency for Clinical Innovation CEC = NSW Clinical Excellence Commission
The tools are designed to assist teams to make changes to improve the way that care is provided while patients are in hospital. This resource acknowledges that care provided in hospitals can be complex and that the solutions to improving both the patient and staff experience will require an interdisciplinary effort. These changes include better communication of the clinical management plan;
a more streamlined approach to planning for transfer of care (discharge)* and a more coordinated inpatient journey.
This resource includes the following components key to implementing CLD:
· a framework for CLD (Figure 4)
· frequently asked questions for implementing CLD (Appendix A)
· patient information leaflet (Appendix B)
· a CLD form (Appendix C) with guidance (Appendix D)
· a suggested transfer of care checklist (Appendix E)
· guidance on collecting patient and staff experience using Patient Experience Trackers (PETs) (Appendix F)
· a protocol/policy for local adaptation (Appendix G)
· a CLD competency set (Appendix H)
· an implementation checklist (Appendix I)
· a draft set of orientation/education slides (Appendix J)
The Context for Change
Increasing demand on our health facilities
In Australia the number of patient admissions continues to increase each year. Table 1 indicates that there was an average 3.2% increase year on year in separations for NSW public hospitals between 2007/08 to 2010/1 . Comparing 2007/08 to 201 /12, demand has grown by 12% (193,865 separations) across the state. With an ageing population and increasing numbers of people with advanced chronic disease who have multiple comorbidities, one would expect that the number of admissions to our health facilities will continue to rise.
Patient transfers of care
Patient transfers of care from hospital occur unevenly through the week, with reduced numbers during the weekend and peaks on Mondays, resulting in the team playing catch up throughout the week (Figure 3). There is also a mismatch between admission and transfer of care times which has an effect on the required number of inpatient beds (Figure 2). This in turn contributes to
bed block. This inefficiency poses a burden of demand on health resources.
The specific problem of peaks and troughs in patient transfers of care are connected with peaks and troughs in staff availability, as well as the peaks and troughs in patient demand. The focus of short to medium term efforts should be on improving the decision making capability of patient care teams, particularly regarding patient care and transfer of care planning.
Figure 2: Medical admissions and discharges in NSW Hospital Facility by hour of day.
Hour of day
120
100
80
60
40
20
0
ADMISSION
DISCHARGE
140
Table 1: AIHW NSW Hospital Separations (2007-2012) 1
0
2
4
6
8
10
12
14
16
18
20
22
2007/08
2008/09
2009/10
2010/11
2011/12
1,466,737
1,505,969
1,542,968
1,582,804
1,660,602
* For the purposes of this resource the terms discharge and transfer of care are used interchangeably to reflect the transfer of professional responsibility and accountability for some or all aspects of care for a patient to another person or professional group on a temporary or permanent basis.
Figure 3: Medical admissions and discharges in NSW Hospital Facility – July 2012
0
10
20
30
40
50
60
ADMISSION DISCHARGE
70
Transfer of care planning is essential to the efficient use of healthcare resources. It is a key part of care planning for patients and should begin at the patients’ admission into hospital as indicated by the NSW Health care coordination policy directive3-6. Transfer of care planning should be seen as a key component of good care planning and care delivery. In short, patients will be ready for transfer as planned, if care is delivered as planned.
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Monday
Tuesday
In addition, the NSW Adult Admitted patient survey results provide an insight into the current patient experience of hospital transfers of care (discharge). NSW hospital patients reported that7:
· they would like to be involved in decisions about their discharge (95%)
· they were not always as involved in discharge decisions as they would like to be (41%)
· services were needed after discharge (72%)
· their discharge was delayed on the day they left hospital (28%)
A Solution – Criteria Led Discharge
One solution that can assist in addressing the demand on beds in our health facilities is to formalise CLD.
CLD will enable the most appropriate healthcare professional to transfer the patient (potentially nursing, allied health or junior medical staff) by providing set criteria for the transfer making process. Under CLD the decisions for discharge are made and criteria are documented by the senior medical clinician (e.g. Senior
Consultant, Medical Fellow, Visiting Medical Officer). The CLD competent staff member (e.g. nursing, allied health, junior medical officer) can then facilitate the discharge of a patient according to the documented criteria. The staff member is then responsible for monitoring that the CLD criteria have been met. If a patient does not meet the agreed criteria they should not be discharged using CLD. The reason should be documented on the CLD form and a medical review will be necessary.
CLD is not:
· a substitute for clinical decision making. A patient should still be seen every day by the medical team.
· staff, other than medical clinicians, independently discharging patients. The CLD competent staff member monitors that the patient has met the documented and agreed criteria.
A formalised CLD process has the potential to:
· Improve patient experience: patients are more involved in their own care decisions, have a clearer understanding of discharge decisions and are able to get home sooner
· Enhance patient safety: a structured approach to transferring care by using a checklist and results in better compliance with discharge instructions8
·
Reduce unnecessary length of stay: patients do not stay in in hospital when they can actually be transferred9
· Minimise waste: reduction of costs as a result of reducing unnecessary lengths of stay in hospital10
· Improve staff experience: staff are not pressured to transfer patients at the “last minute” or experience bed block on Monday due to transfers not occurring over the weekend
While a patient can be identified for CLD at any point in their inpatient journey the interdisciplinary ward round is an ideal time for the team to discuss eligibility. Planning should commence as early as admission.
An Enabler: A Patient Flow Systems Approach
A number of initiatives have been implemented across NSW to improve patient flow.
The Patient Flow Portal (PFP) supports NSW Health workers to adopt a Patient Flow Systems approach by providing accessible, user friendly tools. Specifically, the PFP includes predictive tools to support staff to:
· plan actions according to expected demand
· identify how patients are being allocated according to an expected date of discharge
· view relative length of stay (LOS)
· have a view across varied frames of how a single ward or entire facility is managing
· understand what services patients are waiting for
· have good information on at risk patients
In addition to the PFP, the NSW Ministry of Health commissioned an evidenced based review on Smooth Patient Flow (SPF). To complement this review, the Health Education and Training Institute (HETI) has developed educational and training resources on patient flow. SPF is a learning program divided into three stages.
The objectives of this learning program are to:
· Name the seven elements of the Patient Flow Systems Framework
· Name the five stages of care coordination and identify the key features of each stage
· Explain the seven primary benefits for patients, staff and the organisation that come from using a systematic approach to managing SPF
· Explain how each of the four main functions of the PFP can be used to ensure the systematic management of patient flow
· Analyse a scenario, with a given set of simple data, and determine which interventions, from a selection, would be the most appropriate / effective for improving patient flow for the scenario
It is recommended that the program be completed as follows:
1. Stage 1 – Self-Directed Learning
2. Stage 2 – eLearning module. Depending on your location using either HETI online or moodle.
3. Stage 3 – Continuous Improvement Activities. This stage may be done individually or in local teams and involves a number of activities aimed at reinforcing the principles of smooth patient flow using real world examples.
The Criteria Led Discharge Framework
The NSW Health policy directive on care coordination in public hospitals, Care Coordination: Planning from admission to transfer of care in NSW public hospitals
(PD201 _015) which outlines a five stage process to guide staff and patients through their hospital stay. These are:
1. Pre Admission/Admission
2. Interdisciplinary Team Review
3. Estimated Date of Transfer (Discharge – EDD)
4. Referrals and Liaison for patient transfer of care
5. Transfer of care out of the hospital
In addition to the Policy Directive, there are supporting documents for staff:
· Care Coordination: From Admission to Transfer of Care in NSW Public Hospitals Reference Manual (including the Transfer of Care Risk Assessment)
· Staff Booklet: The Principles of Care Coordination
The five stages of care coordination provide the foundation for CLD (Table 2).
The CLD framework covers the patient journey from pre admission to transfer of care and includes the patient and carer as part of the planning process and the patient care team. The framework is illustrated at Figure 4.
Table 2: Mapping the Criteria Led Discharge Framework to the Care Coordination Policy Directive
Care Coordination Policy Directive
Criteria Led Discharge Framework
1. Pre admission/admission
1. Pre Admission
2. Multidisciplinary Team Review
3. Estimated Date of Discharge
4. Referrals and Liaison
2. On admission
3. During admission
4. Planning for discharge
5. Transfer of Care
5. 24 hours before discharge
6. Day of discharge
Figure 4 Framework for criteria led discharge
NO
Provisional Diagnosis
Assessment and initial intervention/treatment
Pre-admission assessment
/ EDD advised
Unplanned
Planned
Patient indentified and signed off by Fellow/Consultant as eligible for CLD in PART A
Usual care with discharge that includes final medical review
Pre-admission
Diagnosis / Provisional Diagnosis
Ongoing reassessment of treatment goals, timeframes and agreed milestones in partnership with patient/carerConsultant/Fellow signs off patient eligible in PART A/ team documents milestones in PART B
Usual care with discharge that includes final medical review
Clinical management plan agreed by Interdiscipliary Team (IDT) in partnership with patient/carer including:
· A single comprehensive asessment, including an early stage risk assessment
· Outcome and treatment goals with timeframes
· Estimated date of discharge (EDD) that is communicated to patient and entered into the patient flow portal
· Initiation of investigations, commencement of treatment
· Referrals to necessary disciplines
· Communication with community providers (especially if high risk on discharge)
· Interdisciplinary family conferences, where indicated
Discharge planning
Discharge planning by team
Milestones in PART B monitored by CLD competent staff member
Transfer of care (discharge) checklist finalised, including:·
24 hours before discharge
· Personal items returned·
· Medications/scripts provided·
· Discharge summary completed and provided·
· Follow up appointments made, as necessary
· Patient education completed
Patient remains eligible for CLD
YES NOFurther clinical / medical review
NO
YES
Early identification of CLD milestones
Assessment including clinical, functional and social needs
Transfer of Care Risk Assessment
YES
Unplanned Admission
Patient indentified and signed off by Fellow/Consultant as eligible for CLD in PART A
Planned Admission
Admission
NOCLD form finalised. Part C signed off by CLD competent staff member
Transfer of care (discharge) ensuring:·
· Contact details given to patient for appropriate acute sector practitioners for post discharge communication
· Communication with patient’s ongoing care practitioners
Day of discharge
YES
Further clinical / medical review
Implementing Criteria Led Discharge
CLD may be incorporated into the delivery of usual patient care by hospital teams. While CLD is not a project in itself, the implementation of CLD should be managed as a project with a clear project plan and project team.
CLD can be implemented in many ways. The identification of implementing teams will be a local decision. Some hospitals may wish to implement hospital wide; others may wish to implement across wards. To implement CLD you will need, at a minimum:
1. Executive support
2. A co-leadership approach between nursing and medical clinicians, with senior staff leading the implementation
3. An interdisciplinary team approach
In addition then key considerations to implementing CLD are:
· Ensure executive level support
· Analyse data to determine relevant patient population
· Work with clinicians to gain senior medical buy-in and endorsement
· Work with interdisciplinary team to develop a co- leadership model, with senior medical, nursing and allied health (as relevant) buy-in
· Agree range of patient groups with interdisciplinary team and relevant managers
· Clarify roles and responsibilities for interdisciplinary team
· Review systems, processes and establish an agreed target
· Identify skills and training required
· Adopt policy approach, adapting draft protocol for local needs
· Measure baseline patient and staff experience, using the Patient Experience Trackers
·
Refine policy approach in response to
· Feedback from patients and carers
· Feedback from staff
· Incident reports
· Audit
· Capture impact on
· Patient experience (APPENDIX F)
· Staff experience (APPENDIX F)
· Patterns of admissions and discharges by time of day and week
· Comparison with estimated date of discharge
· Key quality and safety metrics e.g. length of stay, readmissions
These steps have been adapted from the UK approach11. A full checklist for teams involved in implementing CLD can be found at APPENDIX I.
Supporting Documentation
A series of documentation is included to support the implementation of CLD. These documents can be adapted according to the needs of each local team.
They are outlined in detail at Table 3 and include:
· frequently asked questions for implementing CLD (Appendix A)
· patient information leaflet (Appendix B)
· a CLD form (Appendix C) with guidance (Appendix D)
· a suggested transfer of care checklist (Appendix E)
· guidance on collecting patient and staff experience using Patient Experience Trackers (PETs) (Appendix F)
· a protocol/policy for local adaptation (Appendix G)
· a CLD competency set (Appendix H)
· an implementation checklist (Appendix I)
· a draft set of orientation/education slides (Appendix J)
Table 3: Supporting documentation for implementing CLD
TOOL
FUNCTION
APPENDIX
Frequently Asked Questions
A one page information sheet for teams implementing CLD
A
Patient Information Leaflet
A one page information leaflet for patients who are part of a CLD process in hospital
B
Generic CLD Form
A draft form that can be used by local teams and may require local forms committee approval. It is not the intention to create a statewide form in the initial phase of this project.
The Senior Medical Clinician is required to sign off that the patient is eligible for CLD. The form also provides a space for noting why the patient was not deemed eligible for CLD. The milestones for the patient to meet should also be documented under the guidance of the Senior Medical Clinician, with the interdisciplinary team, in partnership with the patient and/or their carer. Other team members may add criteria to those set
by the senior medical clinican. This may include both nursing and allied
health staff (e.g. social workers, pharmacists and physiotherapists).
C
Guidance on Completing the CLD Form
This guidance can be adapted depending on the local rules for CLD.
D
Suggested Transfer of Care (Discharge) Checklist
This provides a best practice guide for the structure and a template to develop a local tool for supported transfers of care. It is not intended to replace existing local checklists that are already in place and functional. Implementing teams may wish to audit their existing transfer of care (discharge) checklists against the best practice template provided.
E
Patient and Staff Experience Questions
A short series of questions have been developed for measuring patient and staff experience. Baseline data should be collected prior to
implementation to measure the impact on the ward of CLD. Daily reports are presented in graphical form which are easy to interpret and provide
information to act on in real-time.
F
Draft Protocol/Policy for the Application of CLD
This protocol /policy is designed for local adaptation. The final version should be signed off by the team and outline the locally determined process and principles for clinicians to undertake CLD. The local protocol should also outline how staff are identified as competent to perform CLD.
G
Competency Set
This has been developed for teams wishing to undertake formal assessment of staff competency prior to completing CLD. The full competency pack includes case studies to support the examination of staff competency. The specific staff eligible to perform CLD will be a local decision and may include allied health staff, junior medical officers and/or nursing staff.
H
Implementation Checklist
A suggested checklist for teams involved in implementing CLD.
I
Draft Orientation/ Education Slides
A draft presentation has been developed to educate and orientate new staff regarding the operation of CLD in the local team
J
References
1. Australian Institute of Health and Welfare, Australian hospital statistics 201 –12. , Health services series no.
50. Cat. no. HSE 134, Editor. 2013, AIHW: Canberra.
2. Jessup, R.L., Interdisciplinary versus multidisciplinary care teams: do we understand the difference? Aust Health Rev, 2007. 31(3): p. 330-1.
3. NSW Health Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals – PD2011_015 2011.
4. NSW Health Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospital – Staff Booklet 2011.
5. NSW Health Care Coordination: From Admission to Transfer of Care in NSW Public Hospital – Reference Manual 201 .
6. NSW Health Care Coordination Patient Brochure 2011.
7. Bureau of Health Information, Adult Admitted Patient Survey NSW Jan-Jun 2013, in Healthcare Observer. 2014, NSW Health: Chastwood.
8. Holland, D.E. and K.H. Bowles, Standardized discharge planning assessments: impact on patient outcomes. Journal of Nursing Care Quality, 2012. 27(3): p. 200-8.
9. Walters, M., et al., Criteria Led Discharge (CLD): A Pilot Study Initiative to Reduce Average Length of Stay (ALOS) for Elective Cardiac Procedural Patients. Heart, Lung and Circulation, 2007. 16: p. S181-S182.
10. Webster, J., et al., The effectiveness of protocol drive, nurse-initiated discharge in a 23-h post surgical ward: a randomized controlled trial. International Journal of Nursing Studies, 2011. 48(10): p. 1173-9.
1 . Department of Health, Achieving timely ‘simple’ discharge from hospital – a toolkit for the multi- disciplinary team. 2004, Department of Health.: London.
Appendix A: Frequently Asked Questions for Implementing CLD
CRITERIA LED DISCHARGE – Frequently Asked Questions
WHAT IS CRITERIA LED DISCHARGE?
Under Criteria Led Discharge (CLD) the decisions for discharge are made and documented by the senior medical clinician (e.g. Senior Consultant, Medical Fellow, Visiting Medical Officer).
For appropriate patients CLD competent staff (e.g. nursing, allied health, junior medical officer) can then facilitate the discharge of a patient according to documented criteria. The CLD competent staff member is responsible for monitoring that the CLD criteria have been met.
Criteria Led Discharge is not:
· a substitute for clinical decision making. A patient should still be seen every day by the medical team.
· The nursing (or other staff) independently discharging patients. The CLD competent staff is monitoring that the patient has met the set criteria.
WHAT IS THE PROCESS FOR CRITERIA LED DISCHARGE?
The senior medical clinician identifies eligible patients on PART A of the CLD form and documents a set of criteria on PART B of the CLD form. Identification of patients may occur at any point following discussion between the health care team, led by the senior medical clinician. Other team members may add criteria to those set by the senior medical clinician (PART B).
The CLD competent staff member monitors that the patient has met all the criteria and completes PART C of the CLD form.
WHAT IS A CRITERIA LED DISCHARGE COMPETENT STAFF MEMBER?
The local team will decide on a process for identifying CLD competent staff. The team should maintain a list of such staff; this list should be reviewed at least annually. Some teams identify this staff member with a badge. A competency set has been developed to guide this process.
WHAT IS BEST PRACTICE FOR CRITERIA LED DISCHARGE?
· A patient should be identified as eligible for CLD on admission, or as early as possible.The optimal time for patient transfer of care (discharge) is when a patient is medically stable to leave the hospital and any social and functional issues have been addressed. This is usually when both:
1. the ongoing medical care needs can be provided at home, and
2. when the patient or their carer is confident in their abilities to provide this care.
· The patient must be reviewed every day by the medical team and the set criteria should be updated, if required.
· The criteria and subsequent plan for discharge should be decided in partnership with the entire health care team, including the patient and/or their carer.
· The CLD competent staff member must monitor and record if the patient has met the criteria.
This does not substitute for clinical judgement and if a patient does not meet the criteria a medical review is necessary.
· A transfer of care (discharge) checklist should be completed, this should include a section on the patient education that has been provided.
WHAT ARE THE POTENTIAL BENEFITS OF CRITERIA LED DISCHARGE?
· Improve patient experience: patients are able to get home sooner
· Enhance patient safety: criteria led transfer of care (discharge) through a checklist
· Improve staff satisfaction: not pressured to transfer patients in the “last minute” or experience bed block on Monday due to transfers not occurring over the weekend.
· Reduce unnecessary length of stay: not being in hospital when patients can actually be transferred
· Reduce bed days wasted: elimination of unnecessary days in hospital
· Minimise waste: best use of time-‐poor consultants; reduction of costs as a result of eliminating unnecessary lengths of stay in hospital.
WHERE CAN I FIND MORE INFORMATION ON CRITERIA LED DISCHARGE?
A set of resources is available at:
www.aci.health.nsw.gov.au/cld, these include a/an:
· CLD form with guidance
· suggested transfer of care checklist
· protocol/policy for local adaptation
· competency set
· set of education/orientation slides
· implementation checklist
· guidance for collecting patient and staff experience data using Patient Experience Trackers
The ACI contact for Criteria Led Discharge is Kate Lloyd, Manager, Acute Care 02 9464 4623 or kate.lloyd@aci.health.nsw.gov.au). Your local contact for CLD is
Acknowledgments: Qld Health, The Royal Children’s Hospital Melbourne
Appendix B: Patient Information Sheet for CLD
CRITERIA LED DISCHARGE – PATIENT LEAFLET
Benefits for you
· You’ll know what needs to happen before you can leave the hospital
· You won’t need to stay in hospital any longer than necessary
· You and your family can plan well ahead for leaving the hospital
The estimated date you will leave the hospital is
What is Criteria Led Discharge?
Many people find hospital a worrying and confusing time. Not knowing when they will leave the hospital (discharge) causes many patients a great deal of stress.
Criteria Led Discharge is a process that makes sure your discharge from hospital is not delayed and that you can safely transition home or to another care setting as soon as you are medically ready. It has many benefits:
· it clearly outlines what both you and your healthcare team need to do during your hospital stay
· you spend less time in hospital because decisions about your transfer are made earlier in your stay
· you spend less time waiting for the decision to let you go home
What will happen under Criteria Led Discharge? You and your team agree on a set of milestones for you to meet. Your milestones might include a combination of clinical criteria such as having a normal temperature or not needing a drip, and social (physical) criteria for example being able to be independent where you normally live. These milestones will be documented in your medical record. The team will work with you to meet these milestones so that you can leave the hospital as quickly and safely as possible.
How will you know you have met the milestones? A senior staff member will confirm that you have met all of the agreed milestones. If there are no outstanding issues, you will be able to leave the hospital without seeing your doctor for a final time. If there are any concerns the team will contact the doctor to review your health before going home.
Does this mean you will not see a doctor at all? No. A doctor will continue to see you regularly throughout your hospital stay. Criteria Led Discharge means that you and the team have agreed on a set of milestones. These decisions have been led by the senior doctor. A senior staff member will monitor that these have been met. You will not be discharged before your milestones have been reached.
BEFORE you leave the hospital, please make sure you:
· Understand your care plan for you to manage at home (e.g. medications, follow-up care and appointments)
· Ask about medical certificates, letters and return of private x-rays
· Ask your doctor about any GP or specialist medical follow- up requirements
· Understand any home based support services or community based support that may be available
TALK WITH YOUR DOCTOR
Your doctor will discuss Criteria Led Discharge with you to make sure you both agree to the process
DEVELOP CRITERIA
You and your team agree on a set of criteria (milestones) that you will need to meet in order to leave the hospital
PROGRESS MONITORED
A senior staff member monitors that the agreed milestones have been met
DISCHARGE
You are able to leave the hospital without having to wait to see your doctor
What should you do if you experience problems or are unhappy with your care?
If you are unhappy with any aspect of your care, please ask to speak to the nurse in charge of your ward.
If you do not feel that they are addressing your concerns, ask to speak to the Patient Representative in the hospital. They can be contacted on XXXX-XXXX and their office is located XXXXXXX
Appendix C: Criteria Led Discharge Template
CRITERIA LED DISCHARGE
BARCODE HERE
SMR000000
PART A: MEDICAL REVIEW (to be completed by Consultant or Medical Fellow)
Diagnosis:
I agree for this patient to be discharged once the milestones in part B and C are met.
Estimated Date of Discharge (EDD) on admission
Please do not discharge until medical team review for the following reason (s):
Name: Signature Time/date:
CRITERIA LED DISCHARGE
PART B: Specific patient interdisciplinary team (IDT) discharge criteria (to be completed by IDT)
IDT agreed specific milestones
Name
Designation
Contact
Responsible person:
CLD competent staff member
PART C: PATIENT CRITERIA
Y/N
Name
Signature
All observations Between the Flags within the last 24 hours or within the documented Altered Calling Criteria for this patient
If no, refer to senior medical clinician
Transfer of care (discharge) checklist completed
Reason patient not discharged using CLD protocol:
I confirm that the criteria I parts B and C have been met and are achieved:XXX0000 – 00/0000
Name Designation:
FORM #
Signature: Date/time:
4/12/2013 This form is being tested in XX between XX and XX Page 1 of 1
Appendix D: Guidance on Criteria Led Discharge Form
Criteria Led Discharge for
PART A: Documentation of suitability for criteria led discharge
Please ensure PART A of the Criteria Led Discharge form is filled in by
Expected date of discharge needs to be completed.
PART B: Discharge Criteria
The completion of Part B should be led by the
· 1.
· 2.
· 3.
·
PART C: Patient Criteria
Appendix E: Transfer of Care Checklist
Appendix F: Patient and Staff Experience – Patient Trackers (PETS)
PATIENT AND STAFF EXPERIENCE – PATIENT EXPERIENCE TRACKERS (PETS)
The Patient Experience Tracker (PET) is a small electronic hand held device that can be used to collect patient and/or staff feedback at the point of care (Figure 1). The device can have up to 5 customised questions with multiple choice answers. Patients and staff can respond to each question by the press of a button. It is a fast and effective way to collect patient feedback and measure patient and staff experience. Patients who are cognitively impaired or not competent to answer the questions may have their identified carer complete the survey.
The de-identified data from the devices is collated every day and the reports are sent back via email to nominated staff overnight. The reports are presented in graphical form which is easy to interpret and provides information to act on in ‘Real Time’. A weekly and monthly summary report is also available.
Figure 1: ACI Patient Experience Tracker
The CLD working group has devised a set of patient (Table 1) and staff (Table 2) experience questions to be used to measure pre and post experience for implementing CLD.
Table 1 Criteria Led Discharge Patient Experience Questions
No.
Question
Answer
1
I know the date I am expected to be discharged from hospital
Yes / Unsure / No
2
I am aware of what needs to happen before I am discharged from hospital
Yes / Unsure / No
3
I know who to ask if I have questions about my plan of care
Always Mostly Sometimes Rarely
Never
4
I receive daily updates about my plan of care
5
I am involved in the development of my discharge plan
Table 2 Criteria Led Discharge Staff Experience Questions
No.
Question
Answer
1
I understand what is involved with criteria led discharge
Yes / Unsure / No
2
I involve the patient/family in developing a management plan
Always Mostly Sometimes Rarely Never
3
Our team updates a patient’s estimated date of discharge on admission and throughout the hospital stay
4
I know who to contact if I have concerns regarding a patient’s discharge plan
5
Our team uses a transfer of care checklist (discharge) when planning for a patients discharge
Appendix G: Draft Protocol/Policy For Local Adaptation
Criteria Led Discharge
Category
Clinical
Version Number
xx
.
Relates to Policy (NSW MoH or SNSWLHD Policy)
xx
Effective Date
XXXX
To be allocated by nominated position at site/facility/service upon endorsement
Review Date
XXXX
To be reviewed in 5 years or earlier as required or on receipt of RCA recommendations. To be allocated by nominated position at site/facility/service upon endorsement
Aim
An interdisciplinary team (IDT) decision making approach is utilised in deciding when a patient is fit for discharge.
Discharge delays are avoided by a competent
Indications
The optimal time for discharge is when the patient is medically ready to go home and carers are confident in the ability to care for the patient at home.
Criteria
The criteria for discharge will be determined by each implementing team and approved by the senior medical clinician (Consultant/Fellow). These may be pre-determined and/or individualised for each patient.
Contraindications
Those patients not meeting above criteria.
Alerts/Risks
Nil
Scope
· Visiting Medical Officers (VMO)/Staff Specialists
· Registrars
· Nurse Managers
· Nursing Unit Manager (NUM)
· Clinical Nurse Educators (CNE)
· Clinical Nurse Specialists (CNS)
· Allied Health staff
Local Protocol
A. Equipment, materials and documentation
· Form: Criteria Led Discharge
· Parts A, B and C must be completed on the Criteria Led Discharge Form.
· The CLD form may be used in conjunction with clinical pathways
Criteria Led Discharge Protocol Draft v1
Page 1 of 6 Mandatory compliance is required for all Local Protocol
o The CLD forms will remain in the medical record and a record of MRNs will be kept at the nurses’ station to track patients who have been discharge using CLD.
· EDD and CLD are clearly labelled on patient journey board.
· A clear clinical management plan is still required in the patient medical record.
· Form:
B. Staff Education
· CLD Process
· In Orientation
· Staff competency assessment must be completed prior to conducting CLD
Competency will be assessed by
C. Patient education
· To participate in decision making regarding discharge criteria during IDT rounds
· For planned admissions to be informed at pre-admission clinic of possibility of CLD
D. Sequence of actions
A draft sequence of actions is included at Appendix A. Each implementing team should have a process for signing off their own actions.
Responsibilities
· Director of Clinical Services (Nursing)
Executive and authorising sponsor of the project trial
· Lead Medical Consultants
1. Ensure all medical staff are aware and understand the CLD project and their expectations
· Nurse Manager / Allied Health Team Lead
2. Ensure all nursing and allied health staff are aware and understand the CLD project and their expectations
3. Ensure staff roles(e.g. Nurse Unit Manager (NUM), Clinical Nurse Education (CNE) Clinical Nurse Specialist (CNS), and Allied health are deemed competent in CLD
4. Ensure CLD procedure is adhered to.
· NUM / CNE/CNS / Allied Health Staff
1. Undertake clinical competency in CLD
2. Engage all disciplines in CLD during interdisciplinary rounds
· Staff
1. Ensure a basic understanding of CLD and willingly engage and participate in trial
Outcome Measures
Pre (baseline) and post Patient and Staff Experience collected using Patient Experience Trackers (PETs). Questions have been determined and these are available from the NSW Agency for Clinical Innovation.
Minimum dataset:
Criteria Led Discharge Protocol Draft v1
Page 2 of 6 Mandatory compliance is required for all Local Protocol
· Discharge by Day of Week (% of weekend discharges)
· Discharge by Hour of Day
· Ward Length of Stay
· Ward Mortality
· Ward Traffic (Ward discharges in period of time)
· Surgery cancellations
· Re-admission within 28 Days/ Unplanned Readmissions
· MET Calls (Between the Flags)
· Falls
· Pressure Ulcers
· Medication Prescription Errors
· EDD: Estimated Date of Discharge
· EEDD: Expired Estimated Date of Discharge
· Patient Experience (PET)
· Staff Experience (PET)
CLD form Audit
· % of completed forms
· % of patients discharged
· % patients not discharged on CLD
· % completed transfer of care checklists
· Comparison with EDD
· Patient discharged with documentation
· Transfer of care (discharge) checklist used
Appendices
1. CLD Form 2.
Standards
NSQHS Standard 1 – Governance for Safety and Quality in Health Service Organisations NSQHS Standard 2 – Partnering with Consumers
Safety Considerations
Manual Handling Hand Hygiene Spill Hazard Sharp Hazard Clinical Competency Patient Education Radiation Hazard Cytotoxic Therapy Standard Precautions Electrical Safety
Approved by
Title
Name
Signature
Date
Position Responsible for Adherence & Implementation
Terminology
Ex: National Safety and Quality Health Service Standards (NS & QHSS) Please list and describe key words.
Criteria Led Discharge Protocol Draft v1
Page 3 of 6 Mandatory compliance is required for all Local Protocol
Consultation Process / List
Title / Position
Title/Position Responded
Director of Operations
Director of Clinical Services (Medicine)
Director of Clinical Services (Nursing)
Director of Allied Health
Patient Flow Manager
Allied Health Team Leader
Nurse Manager
Nursing Unit Manager (NUM)
Clinical Nurse Educator (CNE)
Clinical Nurse Specialist (CNS)
Created by
Acknowledgements
Acute Care Taskforce – Improving the Medical Inpatient Journey ACI Manager, Acute Care
Children’s Hospital at Westmead Nepean Hospital
Bega Valley Health Service: Director of Nursing and Midwifery, Patient Flow Project Manager, and Surgical Ward
References
Criteria Led Discharge Protocol Draft v1
Page 4 of 6 Mandatory compliance is required for all Local Protocol
Appendix A
Criteria Led Discharge – Sequence of Actions for
1. A patient must be deemed eligible as early as possible in the admission. For a planned admission this could happen during the pre-admission process.
2. The interdisciplinary team (IDT) reviews patient and identifies eligibility for CLD during rapid/interdisciplinary rounds. The selection of patients must involve a discussion with the treating medical team.
3. Senior Medical Officer (VMO or Fellow) signs off that the patient is eligibile for CLD on CLD form and assigns delegation for discharge to identified staff member (senior nurse).
4. The following pre-set criteria have been agreed by the team:
·
· Off IV medications
· Afebrile >24/24
· Oxygen Saturation > , on room air
· Independent with Activities of Daily Living (ADL), signed off by IDT. Support organised, if required.
· Patient accepted by RCCP (strike out if not relevant)*
· Follow up needs documented
· Medication(s) / Script(s) completed
*insert Respiratory Coordinated Care Program (RCCP) acceptance criteria here and process for this to occur
5. IDT agrees on additional criteria for discharge; these may be a mix of medical, nursing, allied health and social criteria/milestones for the patient to meet/achieve. Criteria/milestones are clearly documented on the CLD form in front of the patient record and linked to the inpatient management plan to ensure smooth transfer of care.
6. As part of this process the IDT agree on estimated date of discharge (EDD) on admission and document this in the CLD form. This can always be reviewed daily and updated in the patient administration system (PAS).
7. The medical staff will discuss the criteria led discharge process with the patient/families and patient/family expectations for discharge.
8. The criteria for discharge will be monitored by the CLD competent staff member
9. The medical staff must ensure a discharge summary is completed and scripts available the day before discharge.
10. All patients on CLD must have had a medical review within 24 hours prior to discharge.
Criteria Led Discharge Protocol Draft v1
Page 5 of 6 Mandatory compliance is required for all Local Protocol
11. A full set of observations must be performed and recorded within one hour of discharge. In addition, any nursing observations that have been regularly recorded during the previous 48 hours should also be performed.
12. If the CLD competent nurse is satisfied the observations are within normal limits for the patient, and the patient has met all of the criteria for discharge, they may be discharged.
13. Patients eligible for CLD should ideally targeted to be discharged by 10am which will therefore require engagement by previous evening and night duty nursing staff.
Approved by
Title
Name
Signature
Date
Criteria Led Discharge Protocol Draft v1
Page 6 of 6 Mandatory compliance is required for all Local Protocol
APPENDIX H: A Competency Statement for Criteria Led Discharge
A Competency Set for Criteria Led Discharge
The health professional safely and effectively discharges a patient applying a criteria led discharge process.
Competency
CLD 1
CLD 2
CLD 3
Locate and read Criteria Led Discharge protocol Discuss the benefits of criteria led discharge
a. For the patient, their carer and/or family
b. For the organisation
Discuss the expectations of the health professional within the criteria led discharge process
Discuss the required authorisation from medical staff for criteria led discharge to occur and identify where this particular information is documented
Discuss the medical review requirements for a patient who will have a criteria led discharge
Demonstrate discussion with the patient, their carer and/or family explaining the criteria led discharge process
Highlight some of the issues that may need addressing when discharging a patient via criteria led discharge
Discuss the discharge follow up required and how this is arranged
I, the undersigned, have demonstrated the necessary knowledge, skills, attitudes, values and/or abilities to be deemed competent in criteria led discharge. I acknowledge that ongoing development and maintenance of competency is my responsibility and will be evidenced in my Professional Practice Portfolio
Health professional
Name Signature
Role Date
I, the undersigned, have observed the necessary knowledge, skills, attitudes, values and/or abilities for
Assessor
Name Signature
Role Date
APPENDIX I: A Checklist for Implementing Criteria Led Discharge
CLD Implementation Checklist for:
Area
Ref
Task
Owner
Timeframe
Status
Governance
1.1
Identify executive lead Name:
Governance
1.2
Identify clinical lead (s): minimum both medical and nursing, consider allied health Medical lead:
Nursing/Midwifery lead:
Allied Health lead:
Governance
1.3
Identify implementation lead
Name:
Governance
1.4
Define, document and agree roles and responsibilities for the clinical leads
Governance
1.5
Define, document and agree roles and responsibilities for the implementation officer
Governance
1.6
Finalise local implementation team
· Terms of Reference
· Regular meeting dates are established
Governance
1.7
Risk assessment
· Identify and manage local implementation risk and issue resolution process
· Involve managers and clinicians (key role map for specific unit)
· Identify any potential barriers and solutions to patient flow
Governance
1.8
Define and measure implementation and outcome measures (see data set). Collect baseline data.
· What local outcomes will be measured?
· At what points of the implementation will you measure outcomes?
· How will you track and report the outcomes?
Operating Design
2.1
Define local protocol (draft available from ACI)
Area
Ref
Task
Owner
Timeframe
Status
Operating Design
2.2
Determine changes to local operating models, procedures and clinical guidelines e.g. adapting existing protocols
Operating Design
2.3
Configure rosters (if required) to accommodate changes brought about by the revised operating model
Operating Design
2.4
Steering Committee sign-‐off
Awareness/Training
3.1
Communication plan/
Communication strategy to report achievements
Data collection
3.3
Collection baseline patient and staff experience data (trackers available from ACI)
Awareness/Training
3.2
Create awareness of the Criteria Led Discharge, impact on existing business processes and ‘go-‐live’ dates for hospital management
Awareness/Training
3.3
Schedule orientation and training sessions for identified clinicians
Awareness/Training
3.4
Ensure patient flow managers are involved in this process
Data/Evaluation
4.1
Define roles and responsibilities for
· IT
· Data and planning team
Data/Evaluation
4.2
· Patient and carer experience with patient story gathering
· Patterns of admissions and discharges by time of day and week
· Compliance with clinician defined estimated date of discharge
· Mortality data
· Ward data (length of stay, traffic)
· Readmission rate
· Audit of CLD form (available from ACI)
· Utilisation and documentation
· % of completed forms
· % of patients discharged
· % patients not discharged on CLD
· % completed transfer of care checklists
· Comparison with EDD
APPENDIX J: A set of education/orientation slides for CLD
Criteria Led Discharge (CLD) : Planning for discharge on admission
25
Name Role XX LHD
Tel | Mob
email
Kate Lloyd
Manager, Acute Care
Agency for Clinical Innovation
Tel 02 9464 4623 | Mob 0467 603 578
kate.lloyd@aci.health.nsw.gov.au
Criteria Led Discharge
LOCAL LHD LOGO
26 Criteria Led Discharge (CLD) : Planning for discharge on admission
Overview
· Improving the medical inpatient journey
· Goals of CLD
· CLD form – PART A, B and C
· FAQ and Patient Information
· Protocol
· Competency set
· Implementation team
· Acknowledgments
LOCAL LHD LOGO
Criteria Led Discharge (CLD) : Planning for discharge on admission 27
LOCAL LHD LOGO
HITH=Hospital in the Home
LHDs=NSW Local Health Districts and Speciality Networks
MOH=NSW Ministry of Health
HETI=NSW Health Education and Training Institute MAU=Medical Assessment Unit
Key
ACI=NSW Agency for Clinical innovation CEC=NSW Clinical Excellence Commission
Educational materials on ‘smooth patient flow’ across the patient journey :
ACI
Leads:
Transfer of Care
Criteria Led Discharge
Clinical Management Plan
Interdisciplinary
Ward Round
PATIENT FLOW
Estimated Date of Discharge Waiting for What
Bed management
Patient in the community
Patient exits service
Inpatient to Inpatient
ED to Inpatient
Patient enters the service
Patient in the community
Improving the Medical Inpatient Journey
HETI
CEC
LHDs
MOH
Hospital in the Home
Medical Assessment Unit
WHOLE OF HOSPITAL: ACCESS TO CARE
28 Criteria Led Discharge (CLD) : Planning for discharge on admission
Goals of CLD
· Improve
· Patient experience
· Staff experience
· Patient safety
· Discharge processes
· Reduce
· Length of stay / waste
· Surgery cancellations
LOCAL LHD LOGO
Criteria Led Discharge (CLD) : Planning for discharge on admission 29
CLD Form – PART A
Senior medical clinician signs of patient as eligible
LOCAL LHD LOGO
30 Criteria Led Discharge (CLD) : Planning for discharge on admission
CLD Form – PART B
Interdisciplinary team document criteria for patient to meet
–
led by Senior Medical Clinician
Local protocol identifies which staff are eligible.
This is clearly documented on the ward.
Individual staff may wear badge to denote they
are CLD competent. LOCAL LHD LOGO
Criteria Led Discharge (CLD) : Planning for discharge on admission
31
LOCAL LHD LOGO
What is CLD?
Why was CLD developed? (benefits)
What will happen?
How will you know you are ready?
Will you still see the doctor?
•
•
•
What is CLD
What is the process? Best practice Potential benefits
Where can I find more information?
•
•
•
•
•
•
•
Information leaflet
•
1 page
Frequently Asked Questions
•
•
Information Sheets
FOR PATIENTS
FOR HEALTH CARE TEAMS
LOCAL LHD LOGO
32 Criteria Led Discharge (CLD) : Planning for discharge on admission
Protocol
· Locally adapted protocol
· Aim
· Scope
· Responsibilities
Competency set
LOCAL LHD LOGO
Criteria Led Discharge (CLD) : Planning for discharge on admission33
Competency
1. Locate and read Criteria Led Discharge protocol
2. Discuss the benefits of criteria led discharge
a. For the patient, their carer and/or family / b. For the organisation
3. Discuss the expectations of the health professional within the criteria led discharge process
4. Discuss the required authorisation from medical staff for criteria led discharge to occur and identify where this particular information is documented
5. Discuss the medical review requirements for a patient who will have a criteria led discharge. This should include a discussion of when a patient may not be suitable for CLD or when the estimated date of discharge (EDD) may change.
6. Demonstrate discussion with the patient, their carer and/or family explaining the criteria led discharge process
7. Highlight some of the issues that may need addressing when discharging a patient via criteria led discharge
8. Discuss the discharge follow up required and how this is arranged
34 Criteria Led Discharge (CLD) : Planning for discharge on admission
Implementation Team
XX XX XX
Kate Lloyd – Manager Acute Care (ACI) 9464 4623,
kate.lloyd@aci.health.nsw.gov.au
Add names and contacts for Local implementation team +/- ACI staff
LOCAL LHD LOGO
Acknowledgements
· ACI Acute Care Taskforce
· ACI Criteria Led Discharge Working Group
· Bega Hospital (Surgical Ward)
· Calvary Mater Hospital (Haematology Unit)
· Wollongong Hospital (Cardiology Step Down Unit, Neurology Ward)Criteria Led Discharge (CLD) : Planning for discharge on admission 35
· Auckland District Health Board
· Queensland Health
· Children’s Hospital Westmead, NSW
· Royal Children’s Hospital Melbourne, VIC
· Department of Health / NHS, UK
LOCAL LHD LOGO
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